Inui, Thomas S. ScM, MD; Frankel, Richard M. PhD
Editor’s Note: This Commentary is a companion piece to the Research Reports by Klitzman (page 447) by Wear and colleagues (page 454) and the Article by Branch (page 463) that appear in this issue. Those papers explore in various ways, as does this Commentary, the growing recognition that how physicians relate to patients as persons has an effect on the overall quality of the care provided. Physicians can foster positive outcomes by attending to a patient’s illness (how they experience their condition), not just their disease. Given that, it is extremely important that students and residents come to understand that how they relate to and refer to patients as people is every bit as crucial as how they approach the diagnosis and management of patients’ diseases.
The distinguished physician Walsh McDermott used the phrase “samaritan medicine”1 to refer to what others might denote as humanistic medicine, humane medicine, patient-centered medicine, or relationship-centered care.2 The diversity of language in use today suggests that we’ve got a big notion surrounded, but are having some difficulty in pinpointing our target. Like the blind men in the Indian parable, we all have some piece of the elephant in our hands, but what we grasp and how we name it differs.
And so it may be, dear readers, with the three special papers in this issue of Academic Medicine. Klitzman3 uncovers what doctors who acquire serious illnesses learn about the experiences, perspectives, and preferences of patients and how they try to put this learning into practice themselves in “Improving Education on Doctor–Patient Relationships and Communication: Lessons from Doctors Who Become Patients.” In “Making Fun of Patients: Medical Students’ Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings,” Wear and her colleagues4 describe medical black humor vis-à-vis patients who are fat, addicted, or uncooperative and wonder if this behavior reflects physicians’ and trainees’ stress, attitudes of superiority, or incredulity. Finally, in “Teaching Respect for Patients,” Branch5 focuses on how to make respect for patients a conscious attitude that manifests itself in intentional, observable, and teachable behaviors. All three papers grapple with issues of relevance to establishing and sustaining health-supporting relationships between patients and doctors, but what do they have in common?
One striking feature of McDermott’s phrase “samaritan medicine” is the relation it has to the parable of the Good Samaritan. Briefly, a traveler (a man from Samaria) sees another man lying by the side of the road who has apparently been badly beaten and needs help. Though the man is a stranger, the bandits may yet be close, and the two men are of very different ethnicities and social status, the traveler stops to give aid—samaritan medicine. By use of this phrase, McDermott invites us to consider the situation and responsibility of physicians to respond with care to the very different other, the alien, the stranger.
The crux and challenge of this situation should be readily recognizable to practicing physicians and those in training to become physicians. The people with whom we interact daily are often strangers, very different from ourselves. They are sick, and we are healthy. They are weak, and we are strong. They act in unaccountable ways and are desperate, afraid, or sometimes abusive. They are old when we are young and young when we are old. They speak different languages, recognize other gods, and see the world working in ways peculiar to us. And here is a different observation, not so much about them as about us—at times, they invoke responses within us that we don’t trust, admire, or find helpful, responses such as anger, disgust, horror, lust, or sheer boredom. Under these circumstances, we recognize the presence of another stranger in the clinical encounter—the stranger within each of us who has these reactions and must, at times, be suppressed because it gets in the way of successful service. At other times, this same “inner stranger” (for lack of a better general language) needs to be brought more explicitly to our consciousness in order that we may mindfully pursue equity (instead of discrimination) in care decisions, understand and manage countertransference phenomena, deepen our capacity for empathy, or acquire greater competency for working across cultures, ages, and/or genders. Humane medicine, humanistic medicine, patient-centered medicine, relationship-centered medicine—all may be founded on understanding what it takes to respond constructively and whole-heartedly to strangers, both to patients and to our innermost selves.
From this perspective, each of the three highlighted articles in this issue may be seen as tackling aspects of “stranger-handling,” to borrow a term from anthropology. Branch describes certain approaches to bring the respectful self more to mindfulness. Klitzman illustrates how experiences of personal illness might assist us to bridge the gulf between us and our patients, and Wear and colleagues assert that when disparaging humor surfaces in our educational environments there is an opportunity to learn something about how we might choose to respond in other ways to patients and others who in some way give offense or trouble us.
To describe some approaches to bridging otherness, we invite you to consider three problematic situations in which estrangement from self and other plays a role. We think you may find these situations familiar. The accounts are written in such a way as to preserve anonymity (names are fictitious) but they are drawn from our experiences.
Vignette 1: Ms. Hattie Smith is a 47-year-old African American woman with hypertension, diabetes, and rheumatoid arthritis, which makes it difficult for her to ambulate. She is a single mother of five children and is morbidly obese. For the past nine months she has been seeing Sarah Stone, an internal medicine resident who intends to pursue a career as a primary care physician. Dr. Stone had been frustrated with Ms. Smith’s failure to lose weight and to keep her blood sugar in check, as well as her seeming indifference to medical recommendations. Dr. Stone’s frustration is evident in her chart notes that read, for example, “Patient’s blood sugar was 400+ taken after a lunch of fried chicken!!!” and “Patient refuses to lose weight.”
Vignette 2: A large health care organization is having difficulties in staff relationships at a variety of levels. Physicians complain that the nurses are slow to do their jobs and are “lazy.” Nurses, in turn, complain that physicians are often disrespectful and treat them like “second-class citizens.” Administrators note that the number of patient complaints about poor service is increasing and are interested in ways to “fix” the problem.
Vignette 3: A 54-year-old patient who was been seen in clinic for follow-up to her surgery for breast cancer later calls the dean of the affiliated medical school “outraged” by the way in which she had been interviewed by a fourth-year medical student in clinic. The patient reports to the dean that she was asked—without any preliminaries—whether she had had a recurrence of her cancer yet. She says that the student’s interviewing style made her feel completely uncared for. “Whatever you’re teaching your students is doing more harm than good,” the patient tells the dean.
What all three of these vignettes have in common is a perception of difference or “otherness” leading to un-samaritan-like outcomes. These difficulties may arise for us naturally. Anthropologists and social psychologists report that individuals and groups often regulate social distance on the basis of perceived similarities and differences. Human ethologists and developmental pediatricians have traced this basic mode of relating to early, even neonatal development. Rene Spitz called it “the smiling response”—the point (around 20 weeks) when an infant is able to distinguish between a stranger and a known person by displaying differential facial expressions and body postures: smiling in the presence of someone known; showing signs of distress in the presence of a stranger. At first, smiling and distress are invariant features of relating. Over time, however, difference and distance become regulated in more subtle ways.6
In medicine, the question of managing otherness and distance in relationships is central. From the Greek physicians onward, the potential for relationship to be a source of healing, i.e., the placebo effect, has been known and practiced for thousands of years. In the contemporary era, specific communication behaviors or competencies that relate to outcomes of care have been identified. There is now evidence that physician communication that is positive and supportive of patients’ autonomy, informed decision making, emotional state, level of literacy, and need for information, among other factors, produces better outcomes than that which is neutral, negative or unsupportive.7–11 Education to enhance and improve physician–patient communication is probably the primary approach today in medical education to close the distance between physician and the patient as other. Occasionally, but not uniformly, communication skills training is integrated with a personal awareness curriculum, enabling student-physicians to enhance their self-knowledge as well as their capacity to come to know patients, to the benefit of both.12
Beyond communication training, are there individual and organizational methods that integrate rather than separate, especially ones that operate at the organizational as well as the individual level? We believe that video review and replay, Appreciative Inquiry, and self-disclosure are three such methods. We’d like to describe each of these in terms of the situation in which it we have applied it.
Video review and replay.
The patient and physician described in Vignette 1 were locked in a story about each other that amplified their differences and took them further and further away from a more inclusive story and solution. Video review has been used as a method for eliciting the physician’s and patient’s “other” story, that is, what they believe but don’t say during the encounter.13,14
Video review and replay is a facilitated opportunity for a physician and patient to observe themselves with the other and comment on what they see. The comments are rerecorded onto a copy of the original encounter in the exact locations where the tape was stopped and the physician and patient are then given an opportunity to hear what each said about the other. In the case of Ms. Smith and Dr. Stone, the physician at one point stopped the tape and said, “I don’t know if I was interrupting her here but it really doesn’t matter because she never loses any weight.” The patient independently stopped the tape at the same point and said, “All she cares about is my weight and blood pressure. I’m not from a middle-class family. I’ve got five children to feed. I just can’t afford the diet she’s recommending.”
Clearly, the physician and patient in this relationship had made assumptions about each other that were preventing them from finding common ground, and co-creating a story that included them both. In reviewing the videotape, the physician said that she was “astonished” because she had never thought to ask the patient if she could afford the diet she had prescribed. The patient, for her part, said that she knew that Dr. Stone cared about her but was having difficulty communicating because she was embarrassed by her economic circumstances and didn’t want to volunteer the information. At their next visit, Dr. Stone apologized to Ms. Smith for not asking if she could afford the diet and negotiated a lower-cost alternative. Ms Smith seemed very appreciative of Dr. Stone’s apology and when she appeared for her next visit, her blood sugar, blood pressure, and weight were the lowest they had been in 18 months. What accounted for this difference in outcome was a story that encompassed both physician and patient and put the “data” in a different light.
Appreciative Inquiry15 is an organizational change strategy that focuses on the question “What’s right with an organization and how can we get more of it?” rather than “What’s wrong with an organization and how can we fix it?” Patient safety and quality improvement models have traditionally focused on identifying and fixing root causes of problems. While this strategy has produced impressive results in some contexts, it does not often address or account for relationships and the underlying dynamics that make relationships work or fail. In some cases, problems of hierarchy and power make it difficult to engage in clear communication; accordingly, it is easier to stereotype someone as a “lazy nurse” or an “arrogant physician” than as a person whose responsibilities also include being a spouse, parent, community member, and so forth.
In the case of the health care system described in Vignette 2, Appreciative Inquiry was used to find a common story with which employees could identify irrespective of their position in the organization. An exercise called “stepping stones” was used in a mixed-group format. The exercise invites participants to take several polished stones out of a basket and use them to “tell the story of how the stepping stones in your life got you from you began to where you are now.” It did not take long before connections that people had never made before began to appear. For example, a nurse and a physician who had worked in the same department for 25 years and had had a particularly difficult time interacting with one another discovered that each played the organ at their respective churches and that outside of the job it was something that gave each of them great satisfaction. Others discovered that they had gone to the same undergraduate institution or even high school but had never known one another. By the end of the exercise, the story of difference and distance that had prevailed had begun to be transformed into a story of similar experiences with common threads. And, while this was only one small activity in a larger attempt to change the organization’s culture, it was powerful in terms of introducing the concept of relatedness and life journey into a context in which these aspects of relationship had largely been ignored. Similar approaches are being used at some schools of medicine to enhance the professional environment (the informal curriculum) in which professionalism is taught and learned.16–18
The patient who called the dean in Vignette 3 was distressed by the way in which she had been treated by a fourth-year medical student, which had angered and upset her. She felt as though the student did not properly attend to her social and psychological needs, thus creating a painful situation that amplified her suffering. The dean, who could easily have dismissed the patient as being “too sensitive” and a complainer, instead invited her to take part in a workshop entitled “The Physician As Patient” in which he and his wife and three other couples presented their experiences. In each couple, one partner was a physician who had faced a life-threatening situation.
The workshop was attended by 25 faculty facilitators for a vertical mentoring program and focused on the challenge of how to teach medical students about suffering. Both partners of each couple were asked to write a page about their experience as a physician/patient or as family member but not share it with their spouse. The workshop began with each person, including the dean, telling their story, then moved to a question-and-answer period, and closed with an opportunity for participants to share their own stories in small groups. The patient who had had such a negative experience in her interaction with the fourth-year student had an opportunity to see and hear the stories of physicians who had become patients and to share her own story in a supportive group context. The day after the workshop the patient, herself a professor in the humanities, e-mailed the dean with the following message. “I have just come from a faculty meeting where I made the statement that the humanities are not being taught at my university, they’re being taught at [your] School of Medicine.” After her involvement in the workshop, the patient subsequently became an adjunct member of the medical school faculty and is teaching students about humanism at the bedside.
Each of these approaches to the three vignettes touches on different aspects of physicians’ capacity to engage with “the other,” as do the three papers in this issue of Academic Medicine. Limits to this capacity may cause relationships to descend into personal distress and dysfunctional interpersonal dynamics. The more the stories we construct or exemplify in our work are about the differences between self and other, the more likely it is that understanding will be tempered, and perhaps distorted, by stereotypical thinking, suppression of true self, defensive posturing, personal isolation, and play-acting rather than the bringing of our whole self to work. Finding a “common story” that joins self and other in each situation is not always easy or possible. Deeper understanding of ourselves as well as of others is apt to be required to succeed in challenging circumstances. More times than not, however, expanding our perspective to ask about each situation—“In this story, where am I? Where is the other? Where is the common good? What, then, should I do?”—will produce a different appreciation of the situation; one in which more of the whole is possible to discern and from which samaritan medicine emerges. In the end, of course, both the Samaritan and the injured man were necessary participants in the story that informs and ennobles us all, even to this day.
1 McDermott W, Rogers DE. Social ramifications of control of microbial disease. Johns Hopkins Med J. 1982;151:302–12.
2 Beach MC, Inui T. Relationship-centered care: a constructive reframing. J Gen Intern Med 2006;21(1 suppl):S3–S8.
3 Klitzman R. Improving education on doctor–patient relationships and communication: lessons from doctors who become patients. Acad Med. 2006;81:447–453.
4 Wear D, Aultman JM, Varley JD, Zarconi J. Making fun of patients: medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Acad Med. 2006;81:454–462.
5 Branch WT. Teaching respect for patients. Acad Med. 2006;81:463–467.
6 Spitz RA, Wolf KM. The smiling response: a contribution to the ontogenesis of social relations. Genet Psychol Monogr. 1946;34:57–125.
7 Duffy F, Gordon G, Whelan G, Cole-Kelly K, Frankel RM. Assessment of competency in interpersonal and communication skills: Kalamazoo II. Acad Med. 2004;79:495–507.
8 Frankel RM, Stein T. The four habits model. J Pract Manag. 2001;16:184–91.
9 Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D. Doctor–patient communication: the Toronto consensus statement. BMJ. 1991;303:1385–87.
10 Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001;4:390–93.
11 Stewart M, Brown J, Donner B, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796–804.
12 Lipkin M J, Kaplan C, Clark W, Novack DH. Teaching medical interviewing: the Lipkin model. In: Lipkin, MJ, Putnam, SM, Lazare A (eds). The Medical Interview. New York: Springer-Verlag, 1995:422–35.
13 Frankel RM, Beckman HB. Impact: an interaction-based method for preserving and analyzing clinical transactions. In: Pettegrew LS (ed). Straight Talk: Explorations in Provider and Patient Interaction. Louisville, KY: Humana, 1982:71–85.
14 Frankel RM, Sung S, Hsu J. Patients, doctors and videotape: a prescription for optimal healing environments? J Altern Complement Med. 2005;11(1 suppl):S31–S39.
15 Cooperrider D. Appreciative Inquiry: An Emerging Direction of Organization Development: Champaign, IL: Stipes Publishing Company, 2001.
16 Inui TS, Cottingham A, Frankel RM, et al. Educating for Professionalism at Indiana University School of Medicine: Feet on the Ground and Fresh Eyes. Professionalism in Medicine: Critical Perspectives. Norwell, MA. Springer Publishers [in press, 2006].
17 Suchman A, Williamson P, Litzelman D, Frankel R, Mossbarger D, Inui T. Towards an informal curriculum that teaches professionalism: transforming the social environment of a medical school. J Gen Intern Med. 2004;19;501–4.